|
Flex | Flex Rx PPO
|
|
Monthly Premium1
Flex: $0*
Flex Rx: $34.80
|
|
In-Network
|
Out-of-Network
|
|
Primary Care Physician
$0
|
Primary Care Physician
$40
|
|
Doctor on Demand
$0
|
Doctor on Demand
$0
|
|
Specialist Copayment
$40
|
Specialist Copayment
30%
|
|
Routine Annual Physical Exam Copayment
$0
|
Routine Annual Physical Exam Copayment
30%
|
|
Urgent Care Copayment
$55 worldwide coverage
|
Urgent Care Copayment
$55 worldwide coverage
|
|
Emergency Room Copayment1
$90 worldwide coverage
|
Emergency Room Copayment1
$90 worldwide coverage
|
|
Ambulance
$255
|
Ambulance
$255
|
|
Outpatient Surgery
$250-$325
|
Outpatient Surgery
30%
|
|
Physical Therapy
$40
|
Physical Therapy
$60
|
|
Inpatient Hospitalization
Days 1-6: $310 per day
|
Inpatient Hospitalization
30%
|
|
Dental Allowance on a prepaid Benefits Mastercard to use at any dentist for all dental services,
routine cleaning/restorative/dentures (not to be used for teeth whitening):
$1,000 reimbursement
|
|
Vision: Annual Routine Eye Exam
$20
|
Vision: Annual Routine Eye Exam
30%
|
|
Frames/Lenses (per year)
$175 reimbursement
|
|
Hearing Care Solutions Hearing Aid Benefit
$599 or $899
|
|
Over-the-counter Benefit
$25 / quarter
|
Over-the-counter Benefit
Not available
|
|
Senior Fit Included
Yes
|
|
CDPHP Life Points® Rewards
Earn up to $125
|
|
Lab Services
$0 or $5
|
Lab Services
30%
|
|
X-rays
$35
|
X-rays
$40
|
|
Advanced Imaging Studies (CT, MRI, etc.)
$135
|
Advanced Imaging Studies (CT, MRI, etc.)
30%
|
|
OOP Max
$6,100
|
OOP Max (Combined)
$9,550
|
|
Plan Documents
Evidence of Coverage (EOC) & Summary of Benefits (SOB) Information
|
|
View a side-by-side comparison
Medicare Advantage Plan Options
Medicare Advantage Plan Options – Western NY
|